The world of clinical nursing is stressful and aggravating and may cause nurses to lose their focus. Learning to deal with work-related stress in a proactive and positive manner may be the most important skill set a nurse may acquire for a career in nursing. Not perfecting those skills could be detrimental-not only to the nurse's career but to himself or herself.

WORK-RELATED STRESS FOR NURSES

It is no secret that the nursing profession is a particularly stressful occupation. Florio, Donnelly, and Zevon (1998) studied oncology nurses and identified significant negative effects related to constant stressors. Shaikh (2004) studied 216 nurses and noted that almost all nurses report severe or moderate stress that specifically links to working conditions. Nedic, Jocic, Filipovic, and Solak (2002) suggested that job stress increases when there is economic crisis in the society such as the United States is currently experiencing. Likewise, Lindo, McCaw-Binns, LaGrenade, Jackson, and Eldemire-Shearer (2006) cautioned that although hospital work involves some very stressful situations, nurses are also affected by non-work-related stress such as family responsibilities and financial difficulties. While the public may be unaware of these facts, most practicing nurses are all too familiar with this kind of stress.

SPECIFIC STRESSORS IDENTIFIED

Multiple stressors have been repeatedly identified for the practicing nurse. Florio et al. (1998) cited coworker stress, ethical concerns, inadequate resources, negative thoughts, physician-related stress, and death and dying as major sources of stress for oncology nurses. Yang et al. (2002) identified the lack of resources and conflict with other professionals as significant sources of stress for nurses in general. Nurses have consistently identified failure to meet patients' needs, self-expectations, workload, and inexperienced coworkers as a real source of work-related stress (Hall, 2004); perception of not having control over a situation increases work-related stress and burnout for nurses (Schmitz, Neumann, & Oppermann, 2000). Shen, Cheng, Tsai, Lee, and Guo (2005) studied psychiatric nurses and identified high job demand, low job control, and low workplace support as significant occupational stressors. French, Lenton, Walters, and Elyes (2000) identified nine subscales of nursing stress, which include death and dying, conflict with physicians, inadequate preparation, problems with peers, problems with supervisors, workload, uncertainty concerning treatment, patients and their families, and discrimination. Nedic et al. (2002) studied physicians, nurses, and laboratory workers for causes of job stress and identified criticism at work, sense of responsibility, low reward, and low support and security at work as significant stressors. In a study to identify variables affecting job satisfaction, 1,780 registered nurses said issues with patient care, nurse managers, and salaries and benefits contributed to their dissatisfaction (Fletcher, 2001). Consequently, Zager and Walker (2005) maintained that the most critical issue is that nurses need to feel supported in their work environment. Stressors that have been identified as hazardous, if prolonged, to the mental and/or physical well-being of nurses are listed in Table 1.

TABLE 1 Hazardous Stressors if Prolonged

These stressors are common among nurses in various practice settings. In addition, research shows that these stressors are not limited to a geographical area but are experienced by nurses in many cultures. Ward and Parsons (2000) asserted that stress is unavoidable in today's fast-paced healthcare environment, and nurses must be alert to the signs and symptoms of stress and how to deal with them.

NEGATIVE EFFECTS OF WORK-RELATED STRESS ON NURSES

Nurses experience numerous negative effects from work-related stressors. Florio et al. (1998) discovered that nurses frequently experience increased health complaints, sleep disturbances, burnout, job dissatisfaction, clinical depression, anxiety, and increased interpersonal problems. These significant work-related stressors contribute to lower mental health scores for nurses (Shen et al., 2005). In addition, Laposa, Alden, and Fullerton (2003) found work-related stress clearly linked to depression and burnout in the emergency department and noted that the accompanying interpersonal conflict was significantly associated with posttraumatic stress disorder. Exposure to daily work stress has been identified as a cause of posttraumatic stress syndrome for Jordanian nurses (Jonsson & Halabi, 2006). Yayli, Yaman, and Yaman (2003) studied 152 nurses in a Turkish hospital and concluded that the majority of them had depressive symptoms and were in need of counseling concerning coping styles. Studies show that high-stress jobs such as nursing elevate levels of anxiety, depression, and psychological distress (Corpley, Steptoe, & Joekes, 1999). Kalichman, Gueritault-Chalvin, and Demi (2000) blamed high rates of occupational stress for nurses' vulnerability to emotional exhaustion, leading them to use avoidance as a coping strategy. In a study of 125 nurses, Kerasiotis and Motta (2004) found significantly high levels of anxiety because of the perceived lack of control in numerous traumatic nursing experiences over a lifetime. Ekedahl and Wengstrom (2006) noted that the coping of nurses under significant work-related stress is more likely to become dysfunctional when there is a lack of human support and boundary demarcation. Hambly (2004) claimed that work-related stress causes psychological, physical, and behavioral problems for nurses and asserted that prolonged stress can produce long-term problems such as hypertension. MacDonald (2006) noted that workplace stress seriously affects female nurses, who are five times more at risk for metabolic syndrome than men are in the same situation. A study examining the effects of job stress/strain on over 21,000 nurses concluded nurses are at higher risk for declining health because of job stress than other professions ("Work-related stress causes decline in nurses' health," 2000). Maher-Brisen (2007) cites addiction as an occupational hazard due to the frequency of which prescription drugs are used by nurses to combat the effects of work-related stress. Orji, Fasubaa, Onwudiegwa, Dare, and Ogunniyi (2002) claimed that nearly half of the 78 nurses they surveyed admitted using diazepam or alcohol to cope with the stress of work. Tomas-Sabado, Aradilla, and Guix (2004) studied 240 registered nurses and confirmed a clear linkage between work-related stress in nursing and the nurse's inability to identify and articulate feelings, especially in communicating with work colleagues. These negative effects are intensely disabling for nurses.

EFFECTS OF WORK-RELATED STRESS ON PATIENTS AND INSTITUTIONS

Work-related stress also has a detrimental impact on patients and institutions. Sveinsdottir, Biering, and Ramel (2005) claimed that occupational stress directly increases turnover rates and decreases job satisfaction, which reduces the quality of nursing care for patients. Kalichman et al. (2000) fault high stress rates for the occupational burnout that nurses experience, which again affects patients. Numerous additional studies show that work environment affects patient outcomes negatively (Laschinger, Finegan, Shamian, & Almost, 2001; Morgan, Semchuk, Stewart, & D-Arcy, 2002; Thyssen, Vaglum, Gronvold, & Ekeberg, 2000).

Abu (2000) noted that excessive work-related stress experienced by nurses puts institutions at risk for litigation under the Occupational Safety and Health Act of 1970, which holds employers responsible for the mental and physical well-being of employees. Nedic et al. (2002) concluded that job stress affects institutions and the healthcare industry through reduced work productivity, absenteeism, and increased medical treatment expenses. The high-stress environment of health care contributes to illness for nurses, translating into absenteeism, high staff turnover, unsafe behavior, and increased accidents (Harris, 2001). With all this at stake, something must be done.

Hambly (2004) claimed that stress is treatable and its effects are reversible, but only if treated early and well. Shader, Broome, Broome, West, and Nash (2001) called for healthcare institutions to consider factors causing stress for nurses and act promptly to create a working environment that retains nurses. Hambly suggested giving clear explanations, addressing the cause of the stress, softening the effects of stress, and changing how the nurse thinks about the situation as helpful. Sveinsdottir et al. (2005) called on institutions to use research findings and implement measures to diminish occupational stress among nurses. Laposa et al. (2003) cited research findings to underscore the important need for hospital administrators to improve the interpersonal workplace climate for nurses. Hambly claimed that work-related stress is caused by poor management and inadequate responses to the problems that cause stress. After studying an intervention program aimed at reducing work-related stress for nurses as a means to increase quality of care, Petterson, Donnersvard, Lagerstrom, and Toomingas (2006) emphasized the importance of involving middle management in planning interventions to reduce nurses' work stress. Jonsson and Halabi (2006) stressed the need for administrators, teachers, and researchers to plan interventions to promote quality of life for nurses while ensuring adequate daily support to relieve work-related stress. Kalichman et al. (2000) called for specific interventions to assist nurses in managing occupational stress to prevent the burnout that is certain to follow. Ohlson and Arvidsson (2005) found positive working conditions essential in helping nurses reflect, feel supported, and have control, all of which prevent the negative effects of occupational stress. Implementing support to increase the nurses' feeling of control in patient care situations will decrease stress and burnout among clinical nurses (Schmitz et al., 2000). Hall (2004) called for staff development educators to use interventional staffing and provide stress debriefing with active coping opportunities while educating clinical nurses. Likewise, Fillion, Fortier, and Goupil (2005) concluded that education is useful in decreasing work-related stress for nurses and improving quality of care for patients; these authors cited increased perceived self-efficacy and decreased psychological distress as outcomes for proper stress and resource education. Ekedahl and Wengstrom (2006) agreed that education should address the dysfunctional coping strategies that nurses use for occupational stress. Mimura and Griffiths (2003) called for additional research to develop and implement effective interventions. Jones and Johnston (2000) echoed the need for additional research to clarify perceived stressors and interventions to address the cause of work-related stress with specific strategies to target health behaviors, lifestyle/risk factors, and self-management skills to amend problematic work environments.

Without a proactive approach to work-related stress, nurses are at high risk for numerous detrimental psychological, physical, and behavioral problems. Stuttle (2005) claims that nurses may create their own work-related stress when they set unrealistic expectations for themselves and decline to employ proven techniques to create a good work-life balance. These unrealistic self-expectations are often birthed of the well-documented, current nursing shortage and high nurse-patient ratios at many institutions.

CALL FOR ACTION

Although many researchers and authors have addressed controlling the amount of work-related stress for nurses, there is a definite gap in the "how to." It is evident that nurses cannot wait for administrators, middle managers, or others to address their stress levels. Practicing nurses must define an acceptable work environment and create it in a positive, proactive manner. Given the proper skills, nurses can craft a therapeutic milieu that will yield benefits to all stakeholders.

Staff development professionals can be key players in equipping nurses for this monumental but extraordinarily rewarding task. These educators can present the literature and validate the nurses' concerns about their work-related stress and consequently call on them to be actively involved in righting the wrongs that create work-related stress. This should happen at all levels throughout the organization. Nurse managers need to acquire the skills needed to model proactive problem solving for staff. Through education and empowerment, nurses can become the best advocates for decreasing work-related stress. As staff development educators teach and model positive reactions to stressful situations daily, they equip frontline nurses to do the same. Helping nurses understand how to positively approach stressors on the job and the value of healthy lifestyles to destress off the job will decrease the possibility of more nurse causalities (see Table 2).

TABLE 2 Steps That Staff Development Educators Can Implement

Repeated stressors such as understaffing, patient overload, lack of support, poor communication and cooperation among professionals, and negative attitudes must be promptly addressed with nursing leading the discussion. If a team member is not assuming his or her share of the workload, peers should not be hesitant to privately explain that he or she is needed to contribute to the team in a productive manner. Nurses too often tolerate counterproductive behavior and attitudes. Team members can and should be held accountably for how they do their job in relation to attitude and behavior as well as skill and knowledge.

In addition, nurses should be encouraged to be professional in their approach to dealing with conflict. An issue need not arise numerous times before being addressed. Prompt attention to the sources of occupational stress allows nurses to be seen as the solution rather than the problem and prevents prolonged internal distress. The temporary discomfort of dealing with problems immediately is less disturbing than the long-term distress caused by avoiding and procrastination.

Lastly, nurses must take ownership of their own stress and well-being. Using healthy, positive stress-reducing techniques can contribute to the overall health of the nurse (see Table 3).

TABLE 3 Positive and Proactive Ways to Deal With Stress

CONCLUSION

In today's nursing world, there is too much at stake to not consider work-related stress a serious issue. Nurses must understand stressors, be empowered to deal with them, and be willing to develop solutions. Staff development educators must display a positive approach to work-related stress, using their teaching skills to make positive change and empowering nurses to design a fitting work environment in which they and patients can be nurtured and cared for.

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